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32 | Allegation: "Staff do not follow Covid-19 protocols." On September 23, 2021 at approximately 9:30 am a visitor observed that three (3) caregiver staff and all residents were not wearing masks. No visitor sign-in sheet or infection control screening was in place. LPAs conducted a visit on October 1, 2021 and upon entry into the facility two (2) out of three (3) caregiver staff were observed not wearing a mask. A total of six (6) staff were interviewed; all staff acknowledged that staff do not always wear masks inside the facility, and/or put them below their chin, or on top of their head. The majority of the residents in care have cognitive impairments and were unaware of COVID-19 infection control practices. Resident (R5) confirmed that many times staff do not wear masks. In addition, based on the physical plant observation on Oct.1, 2021, one (1) bathroom did not have hand soap, paper towels, or hand washing infection control signs in the bathroom. The visitor log was reviewed and showed visitor screening record keeping recently began. Previous visitor logs were not observed.
Allegation: "Staff are sleeping in the common area of the facility." Based on visitor observation on September 23, 2021, staff (S6) was observed laying down in a sofa located in the facility hallway. Staff (S6) was using a cell phone with shoes off. Staff (S6) denied sleeping on the couch, but acknowledged taking breaks in the sofa that is located near the resident rooms. There are currently three (3) live-in caregiver staff in the home. Administrator stated "it is not everyday they lay in the couch." Per Administrator, live-in staff are not awake during night hours and only get up to check on the residents if necessary. Staff (S2) stated that caregivers are allowed to take their breaks in the hallway sofas. According to staff they lay down on the hallway sofas in order to hear the residents better. Staff (S2) stated that moving forward if staff want to lay down and sleep in the sofa they will need to go into the live-in staff room. Resident files were reviewed and it was observed that some of the Dementia residents have not had their physician reports updated since 2017, and the Appraisal Needs and Services Plans have not been completed. In addition, there are 2 residents receiving hospice care services.
See LIC 9099C for report continuation. |
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32 | Allegation: "Residents are not properly dressed while in care." Based on a visitor's observation on September 23, 2021 and observations made by LPAs on October 1, 2021, the findings indicate that the four (4) male residents are not dressed from the waist down. The male residents are left in incontinence diapers all day long without pants, shorts, or pajamas. Resident (R1) was interviewed and confirmed the allegation. Resident (R1) also stated that it would like to wear pants while sitting on the sofa, and pajamas while in bed. The residents did not have blankets covering them. Administration staff stated that the resident's families and hospice are aware. However, on 10/1/2021 the facility was not able to provide documentation that family and hospice agencies instructed the facility to leave the residents in incontinence diapers all day long. Staff stated that the male residents are left in incontinence diapers due to frequent incontinence issues and for medical issues. However, no hospice care plans were observed indicating the residents shall be left uncovered with incontinence diapers. It was not noted on the physician reports.
Allegation: "Facility does not have adequate record keeping." Based on October 1, 2021 observation the findings indicate that the facility records are incomplete, outdated, or missing. The facility documents and resident files were found to be incomplete and missing required forms. Four (4) out of the seven (7) residents had Physician Reports that have not been updated yearly as required if a resident has a Dementia diagnosis. Two (2) of the resident's Physician Reports are dated 2016 and 2017. In addition, a staff roster was requested but not obtained. It is alleged that the facility did not have COVID-19 visitor screening in place as recent as September 23, 2021. Administration staff acknowledged record keeping is not adequate.
Based on document review and observation the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22.
An exit interview was conducted with Administrator Niculina Serban. A copy of the report and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Deficiency Dismissed
Type A
10/07/2021
Section Cited
HSC
1569.50(a)(3) | 1
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7 | The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter: Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California | 1
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7 | Administrator agreed to ensure that facility is following California Dept of Public Health and CCLD requirements. Administrator will submit proof of staff re-training in COVID-19 infection control requirements, and will maintain a safe and healthful environment for residents and staff. |
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14 | This requirement was not met by evidence of: On 10/1/21 at 9:11 am, upon entry into the facility 2 out of 3 caregivers were observed not wearing masks per COVID-19 infection control recommendation. In addition, the facility began screening visitors until after 9/23/21. This poses an immediate health and safety risk to residents in care.
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Request Denied
Type B
10/20/2021
Section Cited
CCR
87705(c)(4)(A) | 1
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7 | Care of Persons with Dementia. In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. | 1
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7 | Administrator agreed to submit a written plan addressing night shift staffing responsibilities, supervision duties, and protocols that ensure residents in care are provided adequate care and supervision. Update the Plan of Operation if needed.
Submit by POC due date. |
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14 | This requirement was not met by evidence of: Based interviews conducted and record review there are 2 residents enrolled in hospice services that require awake night staff. Administrator stated that none of the live-in staff are awake at night. This poses an immediate health and safety risk. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Deficiency Dismissed
Type B
10/20/2021
Section Cited
CCR
87468.1(a)(1) | 1
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7 | Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: | 1
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7 | Administrator agreed to conduct Personal Rights staff training. Proof that all staff received training shall be submitted in the form of a sign-in sheet with training topic.
Submit by POC due date. |
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14 | Based on observation on 10/1/2021 four (4) male residents in care were observed to be laying in a sofa chair and/or bed with only incontinence diapers. The residents did not have blankets covering them. Staff confirmed the residents are left in diapers the majority of the time due to frequent incontinence issues. This poses a potential health and safety risk. | 8
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14 | Admininstrator shall obtain updated Physician Reports for all residents that require a yearly report. In addition, all resident files shall be reviewed to ensure all evaluations are complete. COVID-19 infection control visitor log records shall be completed and available for review.
Submit by POC due date. |
Type B
10/13/2021
Section Cited
CCR
87506(a) | 1
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7 | Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
This requirement was not met by evidence of: | 1
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7 | Admininstrator shall obtain updated Physician Reports for all residents that require a yearly report. In addition, all resident files shall be reviewed to ensure all evaluations are complete. COVID-19 infection control visitor log records shall be completed and available for review.
Submit by POC due date. |
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14 | Based on record review observation facility records are incomplete, outdated, and/or were not found on October 1, 2021 visit. Four (4) out of 7 residents did not have updated Physician Reports on file.
This poses a potential health and safety risk. | 8
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